In this post I want to describe and then share some reflections on a particular piece of community placement practice that I observed at the University of Western Sydney. My aims are to continue to add to the portfolio of descriptive material around community placements with the hopes that this both will resource practice development, encourage thinking about the ways that practice links into other aspects of medical education and also provide a basis and some context for a consideration of the role of the community in the determination of what students should learn from placements and ways that we can assess this learning.
The particular placement practice that I have in mind takes place through an agency called MacArthur Disability Services (MDS), a not-for-profit organisation that provides services and support to people with a range of physical, learning and multiple disabilities who live in Macarthur and Western Sydney. MDS is a community-based, person-centred organisation. It works with people living with a disability, living with or recovering from mental ill-health, the aged and children and young people. Services include support, advocacy and information provision, the creation of opportunities for participation in recreation, leisure, sport and community life, and support with training and into employment. MDS also offers accredited training to professionals, staff and service participants.
MDS takes UWS medical students on placements as part of their Medicine in Context (MiC) course. Placements are a 10 week unit within the third year undergraduate programme comprising successive, 5 week attachments with two non-clinical community-based organisations. During each of these blocks students attend their placement for three days a week and are expected to accrue a total of 90 hours of monitored attendance. The community placement is complemented by one day of campus-based teaching in each week comprising tutorials that partake of and reflect community-based experiences and learning, workshops and seminars. The students also spend one day a week during MiC on placement with a GP.
The MDS model of a placement for a medical student
Structure and activities
A student’s placement with MDS is carefully and relatively highly structured. Students work to detailed, personalised timetable that steers them through an induction process and ‘tasters’ of various aspects of work with service participants towards opportunities to spend more time engaged with those parts of the service which are of particular interest to them. Alongside involvement with service participants, their families and staff and engagement in whatever activities are going on, students are expected to complete a specific task that entails talking to a person at length about disability. They are asked to do this via a face-to-face one-on-one interview conducted over a number of sessions. It is to be written up in the form of narrative that links key issues such as health, medication, lifestyle and personal goals to a medical profile (which they may ask their informant’s permission to see). The whole must be embedded in a critical appraise of relevant research evidence including both medical and non-medical literature. Students’ placements with MDS culminate with the presentation of these pieces of work to MDS staff.
Support, guidance and advice
In common with other UWS community placements, the experience at MDS is based around the formulation of learning agreement drawn between the student and the organisation. This agreement provides a mechanism for linking the intended learning outcomes for the community placement programme to a personal plan of work via a discussion of roles, expectations, interests and aspirations. The plan includes the identification of lines of support, accountability and so on.
In the case of MDS, the process of formulating a personal learning agreement is itself contextualised by an induction programme for students and a comprehensive handbook. The handbook contains information for students, MDS staff and service users and their families including a description of the organisation, an outline of the purpose and structure of the placement, explication of roles, responsibilities and expectations, paperwork relating to monitoring and assessment and an example of a ‘narrative’ of the kind that students are expected to produce along with some specific guidance on how the work will be done, what form it will take, expectations around the quality of writing, referencing and evidence and its presentation.
Ongoing support is available both with this specific task and also as and when needed. As a minimum, students will meet with a named person who coordinates the placement at the beginning and end of every visit. These meetings function as a briefing and de-briefing around activity and learning, respectively.
Characteristics of the placement
This careful structuring of the student placement reflects experience of working with UWS accrued within MDS over a considerable period of time. This has yielded a number of crucial insights into how to maximise both student and organisational benefit.
MDS has high expectations of medical students who undertaken placements with them. This is because the organisation both recognises their intelligence and motivation, skills and capabilities and wants to remind students of the responsibility and power that people will invest in doctors. MDS expects students to live up these expectations. This percolates across the placement experience but was particularly evident in a number of places.
For example, students are expected from the ‘get go’ to work with service participants, their families and staff. They are expected to form deep, intense and personal relationships – even if this exceeds what might be possible in their future practice as a doctor – as it is envisaged that this gives them a sense of the demands that they might face around working at the edge of their comfort zone, and functions as a reminder that people’s engagement with doctors is underpinned by complexity and depth of experience all of which has relevance to the encounter and the interaction.
There is also an expectation that the participant narrative compiled by each student will reflect this, and furthermore be of sufficient quality in terms of the synthesis and appraisal of relevant research that accompanies it, that it can be used a evidence in building the organisation’s knowledge and understanding of participants in its services and in informing the wider world about the impact of disabilities on a person’s life via the MDS website and other resources.
The idea that students will work with people and at the same time with evidence, will compile these into documentary forms which are fit for dissemination is a perceived as a expeditious way of getting them to practice and to feel some of the expectations and responsibilities that they will bear as doctors.
Clarity of purpose and process
I was very struck by the clarity of purpose and process around student placements at MDS. I don’t want to suggest that student experience on this placement is over-determined, nor that all placements must follow this lead but there is something important here about working on a rationale for offering placements as a basis for working out what activities they might comprise. I also see something really interesting going on here around working the processes by which this rationale is created, shared and enacted being useful to the organisation and a lesson to medical students about how principles can inform and drive practice.
One of the reasons that I was so struck by the clarity about purpose and process was that it so clearly rehearsed in a MDS placement handbook. The production of a handbook specific to a student placement represents a considerable investment of time and effort. MDS has made this investment work for them by using it create a context in which to restate and demonstrate the importance that they attach to working with medical students. It seems to me that this also throws down the gauntlet in terms of inviting students to assume the responsibility of returning this investment.
The handbook contains content for students, staff, service participants and their families. There is something very powerful about explicitly outlining how the investment, involvement and expectations of various constituencies of interest come together and in sharing that in via one document.
In the case of MDS all this flows from a simple, straightforward motive: to make the experience of people living with disabilities experience better when they visit the doctor.
This rationale provides the basis for the constructing the placement experience and it is evident in each of the explications of placement respect to service participants, families, staff and students. The version for service participants is a very good example. Here it is captured in a couple of photographs taken from the MDS placement handbook:
I am dwelling on this because I think it helpfully illustrates a number of things. Here’s two which particularly strike me:
First, this provides students with a clear example of the consideration that they should to give the ways that they might communicate with people. It’s an object lesson is clarity, brevity and accessibility.
Second, it provides an example of how organisational principles underpin and drive practice. For example, the phrase, ‘you can teach them…’ represents a clear embodiment and articulation of the principle of being person-centred. For a medical student it might in some circumstances be a helpful corrective to any misunderstanding about where power, knowledge and expertise lies in relation to the task around the participant narrative, for others it might a be helpfully permitting and for all, demonstrate how the relationship between service participants and services is envisioned by MDS.
I also think, although less explicitly evident here, other principles were also imbricated into this statement and the placement experience. For instance, the MDS conceptualisation of disabilities as socially constructed and the basis for discrimination and as a contributor to other forms of social exclusion; the recognition that disability is not a unity category of experience but that individuals have different needs and that an undifferentiated response may add to barriers and exclusion; that choice is a right; participation in the determination of organisational strategy and management foundational to practice; and, that practice should be evidence and needs led.
The commitment shown in the handbook to translating principles and values into professional practice and the demonstration of how that is done is, I think, a valuable contribution to the development of medical students whom the service wants to embody these principle and values and also to find ways of articulating in their practice as doctors.
Creation of a positive learning environment
The community placement at MDS is envisioned as a learning process and hence the environment constructed with that in mind. Staff were clear that an important element of this was exposing students to challenges and then creating opportunities for them to discuss them and consider ways of responding. One thing referred to a number of times was the importance of exposing students to uncertainty – about their abilities, knowledge, competence and so on – and then utilising this to drive reflection and learning. There was something perceived to be something usefully counter-cultural to notion of medical omnipotence in allowing students to talk about being frightened (when faced with service users who might be aggressive) being put on the spot, (asked what they would say to the family of person with a disability about a health issue when there is no definite answer available), and so on, from the perspective of educational practice that assumes owning a lack of confidence and knowledge, and asking questions is of higher value that pretending to competency.
Knowing how this is different to clinical and medical placements but contributes to clinical and medical practice (the dialogic with medicine)
As the above implies, there is evidence of some deep thinking going on here around how the community placement is different to but contributes to clinical and medical practice. For MDS this represents in part the outcome of a dialogue with students over a number of placement cycles and a response to requests for help with seeing the way that community placement experience talks to and informs other aspects of medical education and good medical practice.
I felt that what I was hearing about at MDS was the setting up of opportunities for students to situate themselves at the centre of a dialogic between ‘clinical’ and ‘non-clinical’ community practice. This is theoretical attractive to me because while it provides a means by which to recognise and write about a dichotomy between clinical and nonclinical that is produced by cultures in medical education and medical practice, it also provides a framework in which this dichotomy can be understood as a constructed and indeed constructive in holding the intellectual and experiential spaces apart for reasons fundamentally connected with the way that power orients medical professions, occupations, roles and knowledge.
To give an example which was shared with me by staff at MDS:
Students have been exposed to accounts from service participants where medicine and medical knowledge has intruded in ways that are not simply unhelpful but undermining of the body of knowledge, the expertise of doctor and most importantly, damaging of people’s lives. For instance, in compiling one narrative a student learnt that a family had been told when a child was three years old that as a result of a disability they would never be able to ‘learn anything new’. The person had acquired a wide range of intellectual and social skills in later life. The student had been confronted by the experiences and implications for the family of receiving an inaccurate prognosis. They had seen what kind of role organisations like MDS might play in supporting people in handling that experience and indeed in getting beyond it via defying it. In addition, the student had been forced to consider what constituted evidence (on which the prognosis had presumably been given), how to translate and share that, and the effects on a person’s life chances and their wider social network of getting it wrong. MDS had used the scenario to ask students to consider the following: ‘What will you do as a doctor when presented with this situation?’ What will you say to this person?’ what will you say to their family?’
Mutually beneficial activity and outcomes
MDS has found of way of engaging students in activity that has clear, real and lasting benefits for themselves, for the service and for its users. This occupies a central position in orienting and organising the placement experience and clarifying roles around it, but does not either overwhelm or preclude other forms of engagement and learning.
Other links to medical education
The composition of the participant narrative has other benefits to students in terms of links to other aspects of their education. Clearly, the opportunity to explore the use of evidence with respect to a specific case and to develop a repertoire of skills around reading, analysis, synthesis and presentation of findings represents a useful adjunct to their wider professional and academic development.
Assessment of the UWS placement at MDS
Right back at the beginning of this post, where I described the structure of the community placement at MDS, I mentioned that students are expected to present to staff the narratives that they produce as a culminating demonstration of their placement-related learning. This activity is an important part of the assessment process for the placement and I want to describe this specific example and then relate it the assessment of MiC and placement learning as a whole at UWS.
The point that I driving toward making is that placement learning carries weight for both MDS and UWS, that assessment is an important means of signalling this and that to help negotiate potential problems with instrumental student engagement with assessment it is important to try and find forms of assessment that have a greater rather lesser alignment with the kinds of learning that might be taking place.
To take the specific practice of MDS first. The organisation provides detailed guidance to students on expectations around the project of producing a service participant narrative. Students are directed to the learning opportunities for them (understanding of issues and barriers faced by people living a disability their families and carers; development of communication skills and a range of skills around learning connected with identifying, assimilating and presenting learning, knowledge and evidence), and for the organisation (better more comprehensive records of client need and history, evidence to support training and teaching, and information for the wider public), informed about how they will do they work, and advised on what constitutes an acceptable quality in terms of the outcomes.
The work is presented via an oral presentation to staff whom evaluate the quality of the material, provide feedback and then receive an amended version of the report for publication.
This process is neatly slotted into the UWS requirements for assessment of placement learning. MDS use the presentations to inform their completion of a summative assessment of students via a standardised form including both rating measures against assessment criteria and free text commentary. The provider assesses students on participation, appreciation of diversity, understanding of the various contributors to health inequalities, understanding of the organisation with which they are placed, communication skills and professionalism including attendance.
This assessment is important. The placement provider’s views count for 30% of the assessment of MiC and is given equal weight to a summative essay or poster submitted by the student (in which they reflect on their learning and link it to relevant literature). This is complemented by assessment of engagement and participation in tutorials (20%) and GPs assessment of student learning and participation in the GP placement (20%).
Importantly, the placement provider and GP assessments are aligned along the same assessment criteria further emphasising the valuation attached to both non-clinical and as well as clinical community experience.
The community in medical education: the business of deciding what doctors are for, what they need to know and who can decide it they know it.
The value and importance attached to assessment of student learning and experience in the context of community placement by both UWS and MDS set me thinking about assessment in medical education and indeed the determination of what medical is for more generally and, in particular, the role of the community in these endeavours.
It seems self-evident to me that if we value the contribution of the community to medical education then we should recognise that in the assessment of students’ learning. This should be robust, proportionate, equitable and so on. While issues about achieving this in relation to practice which is by nature about diverse learning contexts and experiences and overseen by people from a wide variety of professional and other backgrounds may seem challenging I think that they are resolvable. Without beginning to consider specific mechanisms (whether the UWS model or others) I think some principles are worth considering.
The first derives from the sedimentation of ideas arising from my encounter with MDS precipitated by a question that I was asked during the course of seminar that I gave at UWS on non-clinical community-based education (which I will make available via this blog shortly). I was asked what evidence we might have for the contribution of placements to student learning and good medical practice. I heard myself waffling in response about needing to build a clear idea of practice and develop a picture of the range of potential outcomes (go to the 116 mentioned elsewhere in this blog) as the basis for thinking about what kinds of evidence we might look for, where and how. It was a well-intentioned by essentially evasive answer. I was rescued by another participant in the event who observed that one thing to do would be to ask the community what the outcomes of non-clinical community placements should be. Indeed, to go further and ask, ‘What would you like a doctor to be like?’ as a basis for thinking about what medical comprises.
This is a potentially radical idea. It gives us much to think about.
How is the community already perceived to be involved in setting the agenda for medical education and the determination of outcomes as a basis for involvement in assessment? It could be argued that medical education and what we assess is constructed with a close focus on communities. That community needs are the driver of education whether they are to be found represented in epidemiology, perceptions of needs, preference for care, and so on. I think this in an overly optimistic and narrow reading of what is possible and what might be implied by community involvement in placement-related learning assessment and downplays the kinds of obstacles that this might run up against.
First, there is the issue of who determines these needs, how and what representation communities have directly in places where this happens and how these then shape medical education. Is the vested interest of the profession, regulatory bodies and so on informed by ‘user’ voices and experiences or are these voices given direct access to determination of medical education through speaking to the issue of what doctors are for?
Second, there is the issue of what taking communities in medical education seriously means for the resourcing of their involvement. Should we building community-based capacity to train and support medical students and also assess their learning? Would this help future doctors to see the community as what it is, the source of expertise and information which they need to inform and resource their practice?
And, to turn back to the specific issue of involving community partners in assessing placement learning, how does this relate to other forms of assessment? I think we should be positive that it can tell us much. For example, it is striking that students at UWS who struggle with early non-clinical exposure in terms of professionalism often struggle later in clinical contexts. This could be a demonstration both that non-clinical education is relevant and produces valid evaluations of students. It’s not outside medical education, providing adjunct skills and learning but core and the context where students who will struggle with other aspects of medical education and practice might be identified.
Despite the questions emerging here around capacity, skill, resource issues and so on, with regard to community involvement in medical education and its assessment I think that we have not to let such considerations become excuses for an unwillingness to trust people, respect them and equip them to come up with solutions to own problems. There is implied here a contribution via community-based medical education to the drift away from a patriarchal conception and practice of medicine, position and positioning of doctors. It is may be inferred that power does not equate to knowledge, and that the ability to answer the questions posed to doctors by communities may not arise from a concentration of power and responsibility in doctors and medicine but a return of some of that power and responsibility to the community itself. A good place to start might be with allowing communities more and more direct influence in and on medical education.
I think that this might take us back what MDS is doing. That is, taking a set of principles and values, and creating structures and systems around them. That feels rather exciting to me. It is clearly not without challenges. In the context of medical education these might seem particularly crystalline when it comes determination and assessment of specialist knowledge. But, I think I am arguing that this is a minor problem and not to be distraction from putting the primary question as guide to where we start, ‘What kind of doctor does the community want?’